Citation Nr: 20021513 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 18-21 986 DATE: March 26, 2020 ORDER Entitlement to service connection for a depression and adjustment disorder, secondary to the service-connected disabilities, is granted. Entitlement to a rating higher than 60 percent for hypertension with nephrosclerosis is denied. Entitlement to ratings of 100 percent prior to June 1, 2014; 10 percent from June 1, 2014 to May 11, 2016; 100 percent from May 11, 2016 to December 1, 2016; and 10 percent from December 1, 2016 for ischemic stroke are granted. Entitlement to a rating higher than 0 percent for residuals of septoplasty, claimed as deviated septum is denied. Entitlement to a rating higher than 0 percent for erectile dysfunction is denied. Entitlement to a rating higher than 50 percent for obstructive sleep apnea is denied. Entitlement to an effective date earlier than December 4, 2013, for service connection for hypertension with nephrosclerosis is denied. Entitlement to an effective date earlier than December 4, 2013, for service connection for ischemic stroke is denied. Entitlement to an effective date earlier than December 4, 2013, for service connection for erectile dysfunction is denied. Entitlement to an effective date earlier than August 18, 2016, for service connection for residuals of septoplasty, claimed as deviated septum is denied. Entitlement to an effective date earlier than August 18, 2016, for service connection for obstructive sleep apnea is denied. For the periods from December 4, 2013, to June 1, 2014, and from May 11, 2016, through December 1, 2016, special monthly compensation (SMC) based the housebound criteria is granted. REMANDED Entitlement to service connection for a disability manifested by loss of equilibrium is remanded. Entitlement to special monthly compensation based on the need for the aid and attendance of another person is remanded. FINDINGS OF FACT 1. Throughout the appeal period, hypertension with nephrosclerosis has manifested with a BUN reading no higher than 16 without persistent albuminuria. 2. The Veteran had ischemic strokes on November 8, 2013, and May 11, 2016; throughout the appeal period, the Veteran had subjective symptoms related to the ischemic stroke, including subjective left side numbness. 3. Throughout the appeal period, residuals of a septoplasty have not been manifested by 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 4. Throughout the period of appeal, erectile dysfunction is manifest by a loss of erectile power, but no penile deformity. 5. Throughout the period of appeal, sleep apnea has required the use of a CPAP machine, but the evidence does not show sleep apnea with chronic respiratory failure with carbon dioxide retention or cor pulmonale, or sleep apnea requiring a tracheostomy. 6. Resolving all reasonable doubt in favor of the Veteran, the evidence supports a finding that the Veteran has a psychiatric disability that is related to the service-connected disabilities. 7. No communication earlier than December 4, 2013, from the Veteran may be reasonably construed to be a claim, formal or informal, for service connection for hypertension with nephrosclerosis, ischemic stroke, or erectile dysfunction. 8. No communication earlier than August 18, 2016, from the Veteran may be reasonably construed to be a claim, formal or informal, for service connection for residuals of septoplasty, claimed as deviated septum. 9. A May 2015 rating decision denied service connection for sleep apnea. The Veteran was notified of the decision and of his appellate rights but did not appeal of the denial of service connection for sleep apnea. 10. VA received the Veteran’s informal claim to reopen the previously denied claims for service connection for sleep apnea on August 18, 2016. 11. From December 4, 2013 to June 1, 2014, and from May 11, 2016 through December 1, 2016, service-connected ischemic stroke is rated at 100 percent, and the Veteran’s other service-connected disabilities are independently rated at 60 percent or more. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 60 percent for hypertension with nephrosclerosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7,4.104, 4.115b, Diagnostic Codes 7507, 7101. 2. The criteria for ratings of 100 percent prior to June 1, 2014; 10 percent from June 1, 2014 to May 11, 2016; 100 percent from May 11, 2016 to December 1, 2016; and 10 percent from December 1, 2016 for ischemic stroke have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.124a, Diagnostic Code 8009. 3. The criteria for a rating higher than 0 percent for residuals of septoplasty have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.97, Diagnostic Code 6502. 4. The criteria for a rating higher than 0 percent for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.115b, Diagnostic Code 7522. 5. The criteria for entitlement to a rating in excess of 50 percent for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.97, Diagnostic Code 6847. 6. The criteria for service connection for a psychiatric disability, claimed as depression, have been met. 38 U.S.C. §§ 1110, 1131, 1132, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.310. 7. The criteria for an effective date for service connection for hypertension with nephrosclerosis prior to December 4, 2013 have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400. 8. The criteria for an effective date for service connection for ischemic stroke prior to December 4, 2013, have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400. 9. The criteria for an effective date for service connection for erectile dysfunction prior to December 4, 2013, have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400. 10. The criteria for an effective date for service connection for residuals of septoplasty, claimed as deviated septum prior to August 18, 2016, have not been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400. 11. The May 2015 rating decision that denied service connection for sleep apnea is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104(a), 20.302(a), 20.1103. 12. The criteria for an effective date earlier than August 18, 2016 for service connection for sleep apnea are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.1, 3.102, 3.155, 3.400. 13. From December 4, 2013, to June 1, 2014, and from May 11, 2016, through December 1, 2016, the criteria for SMC based on housebound status have been met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Rating Disability ratings are determined by the application of VA’s Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). 1. Entitlement to a rating higher than 60 percent for hypertension with nephrosclerosis The Veteran seeks entitlement to a higher rating for service-connected hypertension with nephrosclerosis, which is currently rated at 60 percent. The Veteran is currently rated under 38 C.F.R. § 4.115b, Diagnostic Code 7507, which provides that arteriolar nephrosclerosis is rated according to predominant symptoms as renal dysfunction, hypertension, or heart disease. If rated under the cardiovascular schedule, the percentage rating which would otherwise be assigned will be elevated to the next higher rating. 38 C.F.R. § 4.115b, Diagnostic Code 7507. Under Diagnostic Code 7507, a 30 percent rating is provided for albumin constant or recurring with hyaline and granular casts or red blood cells; or, transient or slight edema or hypertension is at least 10 percent disabling under Diagnostic Code 7101. A 60 percent rating is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension is at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating is warranted for persistent edema and albuminuria with BUN 40 to 80mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating is warranted for renal dysfunction requiring regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.115a. Diagnostic Code 7101, for rating hypertension, provides that a 20 percent rating is warranted where diastolic pressure is predominantly 110 or more, or where systolic pressure is predominantly 200 or more. A 40 percent rating is warranted where diastolic pressure is predominantly 120 or more. A maximum rating 60 percent rating is warranted where diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104. Under 38 C.F.R. § 4.104, Diagnostic Code 7000, which addresses valvular heart disease, a 100 percent rating is warranted during active infection with valvular heart damage and for three months following cessation of therapy for the active infection. Thereafter, a 100 percent rating is warranted with valvular heart disease (documented by findings on physical examination and either echocardiogram, Doppler echocardiogram, or cardiac catheterization) resulting in: chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. A 60 percent rating is warranted when there is more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 30 percent rating is warranted when workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electro-cardiogram, echocardiogram, or X-ray. A 10 percent rating is warranted when workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; continuous medication required. The present claim for a higher rating was filed in August 2016. On VA hypertension examination in March 2017, the examiner noted that over the prior 12 months, the Veteran had blood pressure readings of 182/100 in February 2017, 138/100 in January 2017, and 183/100 in September 2016. The examiner noted that within that 12-month period, 14 other blood pressure readings had diastolic blood pressure readings of less than 100. The treatment plan included taking continuous medication for hypertension. At the examination, the examiner took blood pressure readings of 183/115, 197/114, and 177/103, for an average reading of 182/110. The examiner stated that the Veteran did not have a history of a diastolic blood pressure elevation to predominantly 100 or more. The examiner opined that hypertension did not impact the ability to work. On VA nephrology examination in March 2017, the examiner diagnosed of nephrosclerosis. The examiner noted that the last nephrology clinic note from September 2016 indicated that the Veteran was non-proteinuric. A September 2016 lab report showed that the Veteran’s BUN was 13, creatine was 1.43, and eGFR was 62. A May 2016 lab record showed GFR of 52, creatinine of 1.7, and a urinalysis was negative for blood or protein. The urine microalbumin/creatine ratio was normal. The examiner concluded that there was no evidence of persistent hematuria, persistent proteinuria, or persistent GFR of less than 60. The Veteran’s treatment plan included taking continuous medication. The examiner indicated that the Veteran did not have renal dysfunction. The examiner further opined that the Veteran’s kidney condition did not impact his ability to work. Based on a careful review of the subjective and clinical evidence, the Board finds that the Veteran’s hypertension with nephrosclerosis does not warrant a rating in excess of 60 percent. In so finding, the Board notes first that Diagnostic Code 7101, governing hypertension, allows for a maximum schedular rating of 60 percent. As the Veteran is currently in receipt of the maximum 60 percent rating, a higher rating is not warranted for hypertension with nephrosclerosis under the rating criteria governing hypertension. The Board finds that a higher rating is not warranted for the Veteran’s hypertension with nephrosclerosis under the rating criteria governing heart disease. No congestive heart failure, cardiac hypertrophy, or cardiac dilatation has been documented at any point during the appeal period. The Board finds that a rating in excess of 60 percent is not warranted for the Veteran’s hypertension with nephrosclerosis under the rating criteria for renal dysfunction. During the appellate period, the Veteran’s BUN has never been 40 or more, and symptoms of renal dysfunction have not included persistent albuminuria. Significantly, the March 2017 nephrology examiner found no renal dysfunction nor persistent proteinuria, and a BUN level of 13. Notably, the examiner opined that the kidney condition did not impact the ability to work. Thus, a rating higher than 60 percent is not warranted under Diagnostic Code 7507. In reaching the above conclusions, the Board acknowledges that the Veteran sincerely believes his symptoms to be more severe than contemplated by the currently assigned 60 percent rating. The Veteran is competent to report on factual matters of which he has first-hand knowledge, such as experiencing an increased level of symptomatology. Washington v. Nicholson, 19 Vet. App. 362 (2005). However, he is not competent to identify a specific level of disability under the appropriate diagnostic codes, particularly where that requires diagnostic testing and medical opinion. The Board find that the most probative medical evidence has shown that the Veteran’s hypertension with nephrosclerosis is no more than 60 percent disabling under any relevant rating criteria. The Board finds that examination evidence more probative because of the diagnostic testing conducted and the medical training of the examiners. Accordingly, the Board finds that the preponderance of the evidence weighs against a finding that a rating in excess of 60 percent for hypertension with nephrosclerosis is warranted. Therefore, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to a rating higher than 10 percent for ischemic stroke The Veteran seeks entitlement to a higher initial rating for service-connected ischemic stroke, which is currently rated 10 percent. The Veteran is currently rated under 38 C.F.R. § 4.124a, Diagnostic Code 8009. Diagnostic Code 8009 provides a rating of 100 percent for the six months following a cerebrovascular accident, with a minimum 10 percent rating assigned thereafter and separate ratings for any residuals of the cerebrovascular accident. 38 C.F.R. § 4.124a. Neurological conditions, except as otherwise provided, will be rated in accordance with a schedule of ratings set out at 38 C.F.R. § 4.124a , which provides that, with the exceptions noted, disability from the following diseases and their residuals may be rated from 10 percent to 100 percent in proportion to the impairment of motor, sensory, or mental function. Consideration is to be given to psychotic manifestations, complete or partial loss of use of one or more extremities, speech disturbances, impairment of vision, disturbances of gait, tremors, visceral manifestations, etc., referring to the appropriate bodily system of the schedule. With partial loss of use of one or more extremities from neurological lesions, rating shall be by comparison with the mild, moderate, severe, or complete paralysis of peripheral nerves. A Note to 38 C.F.R. § 4.124a provides that it is required for the minimum ratings for residuals under diagnostic codes 8000-8025, that there be ascertainable residuals. Determinations as to the presence of residuals not capable of objective verification, i.e., headaches, dizziness, fatigability, must be approached on the basis of the diagnosis recorded; subjective residuals will be accepted when consistent with the disease and not more likely attributable to other disease or no disease. It is of exceptional importance that when ratings in excess of the prescribed minimum ratings are assigned, the diagnostic codes utilized as the bases of evaluation can be cited, in addition to the codes identifying the diagnoses. An April 2017 rating decision found a clear and unmistakable error in a December 2014 rating decision which granted service connection for the ischemic stroke and combine the rating with service connection for hypertension and nephrosclerosis. A separate 10 percent rating was established for ischemic stroke, effective December 4, 2013, pursuant to Diagnostic Code 8009. A rating of 100 percent was assigned effective May 10, 2016, and the 10 percent rating was re-established effective December 1, 2016. The date of the 100 percent rating was later adjusted to May 11, 2016. The Veteran appealed the initially assigned rating. Outpatient medical treatment records note that the Veteran had a stroke and was released from the hospital on November 8, 2013. On VA examination in December 2014, the examiner found that the Veteran had no neurological residuals or functional limitations due to ischemic stroke. Cranial nerves II through XII were grossly intact. The Veteran’s muscle strength was 5 out of 5 in the bilateral upper and lower extremities. Heel to toe walking was intact. Tandem walking was normal. The Veteran’s coordination and speech were normal. No focal neurological deficits were noted. On May 11, 2016, the Veteran was admitted to the hospital for a stroke. On VA central nervous system examination in March 2017, the examiner noted that the Veteran experienced ischemic strokes in 2013 and 2016. The examiner stated that the Veteran developed an ischemic stroke in 2013 without any residual or functional limitations, and he developed another ischemic stroke in May 2016 after presenting with left sided numbness. The Veteran’s numbness had improved, but not completely resolved. The Veteran’s condition required continuous medication for control. The Veteran did not have any muscle weakness, swallowing conditions, respiratory conditions, sleep disturbances, bowel functional impairment, or voiding dysfunction as a result of the central nervous disease, to include as a result of treatment or a residual of treatment. The Veteran’s speech was normal. The Veteran walked with a wide-based gait. The examiner noted that the Veteran reported subjective numbness to the medial aspect of the left lower arm; sensation was otherwise intact throughout the upper and lower extremities. The examiner found no objective evidence of weakness or any other functional impairments that would affect the Veteran’s ability to work. The examiner specified that the Veteran did not have a mental health condition attributable to a central nervous system disease or its treatment. The Veteran regularly used a cane. The examiner specified that the Veteran used the cane due to his disequilibrium, which was not due to the stroke. The examiner opined that the Veteran’s central nervous system disorder did not impact his ability to work. Based on the evidence of the record, the Board finds that Veteran is entitled to a rating of 100 percent from December 4, 2013, through June 1, 2014. Under 38 C.F.R. § 4.124a, Diagnostic Code 8009, a 100 percent rating is warranted for 6 months following the brain incident. An ischemic stroke occurred on November 8, 2013. However, the effective date of service connection is December 4, 2013. Therefore, the portion of the 6-month total rating available to the Veteran under Diagnostic Code 8009 subsequent to the brain incident comprises the period from December 4, 2013, through June 1, 2014 and is granted in this decision. The Veteran experienced another ischemic stroke on May 11, 2016. The 6-month total disability rating available to the Veteran under Diagnostic Code 8009 was previously awarded by the AOJ and properly extends from May 11, 2016, through December 1, 2016. Concerning the other periods on appeal not covered by the temporary total ratings, the Board notes that the Veteran has reported experiencing disequilibrium. The December 2017 VA examiner specified that the Veteran’s disequilibrium was not due to the stroke. Therefore, it is not a symptom to be considered in rating the ischemic stroke. In a November 2018 statement, the Veteran’s spouse stated that the Veteran had to use the restroom about every hour. She stated that the Veteran wore absorbent garments. However, the December 2017 VA examiner also specified that the Veteran did not have voiding dysfunction as a result of the ischemic stroke, to include as a result of treatment or a residual of treatment. As the medical evidence indicates that the voiding dysfunction is not due to the stroke, it is also not a symptom to be considered in rating the ischemic stroke. The Veteran has also reported experiencing left-sided numbness. The May 2017 VA examiner indicated that the numbness of the left lower arm was subjective. Sensation was otherwise intact throughout the upper and lower extremities. However, the Note to 38 C.F.R. § 4.124a requires that the symptoms be objective and measurable. As the medical evidence indicates that the reported numbness is subjective as opposed to objective and measurable, a higher or separate rating for that symptom is not warranted. In reaching the above conclusions, the Board again notes that the Veteran is competent to report on factual matters of which he has first-hand knowledge, such as experiencing an increased level of symptomatology. Washington v. Nicholson, 19 Vet. App. 362 (2005). However, in this case, the Board finds that the Veteran’s statements are outweighed by the medical evidence of record, as the medical records were prepared by objective professionals who had the training and education necessary to offer objective, competent medical observations and opinions. The Board find that the most probative medical evidence has shown that the ischemic stroke is no more than 10 percent disabling under any relevant rating criteria outside of the periods for which limited duration 6-month total disability ratings have been assigned. In summary, ratings of 100 percent prior to June 1, 2014; 10 percent from June 1, 2014, to May 11, 2016; 100 percent from May 11, 2016, to December 1, 2016; and 10 percent from December 1, 2016, for ischemic stroke are granted. The Board finds that the preponderance of the evidence is against the assignment of any higher ratings. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to a rating higher than 0 percent for residuals of septoplasty, claimed as deviated septum The Veteran’s residuals of a septoplasty are rated pursuant to Diagnostic Code 6502, used for rating traumatic deviation of the nasal septum. A 10 percent rating is warranted when there is 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side. 38 C.F.R. § 4.97, Diagnostic Code 6502. The present claim for a higher rating was filed in August 2016. On VA examination in March 2017, the examiner observed that the Veteran had a straight nasal septum, and the bilateral nares were patent. The examiner remarked that the Veteran had a traumatic nasal septal deviation sustained while he was on active duty that was subsequently repaired while the Veteran was in the service. The examiner stated that the septum was currently straight without deviation, and the Veteran had no reported nasal breathing difficulties. The examiner opined that the condition did not impact the ability to work. The VA treatment records have not shown obstruction of the nasal passages. Therefore, the Board finds that the probative evidence of record does not document that the residuals of a septoplasty have resulted in 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side for any period on appeal. To the extent that the Veteran has reported observable symptoms, such as difficulty breathing through his nose, those reports are probative evidence which have been properly considered by the Board. Layno v. Brown, 6 Vet. App. 465 (1994). However, to the extent that the Veteran asserts that the residuals of a septoplasty have resulted in 50 percent obstruction of the nasal passage on both sides or complete obstruction on one side for any period on appeal, the Board finds that those statements, while competent, are less probative and persuasive than the objective medical findings from trained medical examiners, as the Veteran lacks the medical expertise to properly asses the condition. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds that the findings of the examiners are more persuasive because of their medical training. Accordingly, the Board finds that the preponderance of the evidence is against the claim of entitlement to a rating higher than 0 percent for residuals of a septoplasty for the entire period on appeal. Therefore, the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a rating higher than 0 percent for erectile dysfunction Because the Veteran’s erectile dysfunction is not specifically listed in the rating schedule, it is rated by analogy based upon the closest affected body system. When an unlisted disability is encountered, it is to be rated under a closely-related disease or injury similar in function and anatomical location. 38 C.F.R. § 4.20. Here, the closest analogous disability is Diagnostic Code 7522, which provides a 20 percent rating for deformity of the penis with loss of erectile power. 38 C.F.R. § 4.115b, Diagnostic Code 7522. The present claim for a higher rating was filed in August 2016. On VA central nervous system examination in March 2017, the examiner stated that the Veteran was not able to achieve an erection with medication sufficient for penetration and ejaculation. On VA reproductive system examination in March 2017, the Veteran reported that he was unable to obtain an erection. He was not taking any medication to treat erectile dysfunction. It was noted that the Veteran was unable to achieve an erection sufficient for penetration and ejaculation without medication. The Veteran’s penis, testes, and epididymis were not examined pursuant to the Veteran’s request. The Veteran reported having normal anatomy with no penile, testicular, or epididymis deformity or abnormality. The examiner opined that the erectile dysfunction did not impact the ability to work. Based on the evidence of record, the Board finds that erectile dysfunction does not warrant rating higher than 0 percent at any time during the period of appeal. A review of the evidence shows that while the Veteran clearly has difficulty getting or maintaining an erection, he has not had penile deformity at any time pertinent to the current appeal. While the medical records as reviewed above clearly indicate that the Veteran is prescribed medication for erectile dysfunction, none of the medical evidence indicates that the Veteran’s penis is actually deformed. Additionally, the Veteran has never claimed that he has an actual penile deformity in addition to the erectile dysfunction. As the evidence does not show that the Veteran experiences the symptom of a penile deformity in addition to the erectile dysfunction, an initial compensable rating is not warranted for erectile dysfunction. The preponderance of the evidence is against the assignment of a higher rating, and the claim must be denied. 38 C.F.R. §§ 4.31, 4.115(b), Diagnostic Code 7522. The Board notes that the Veteran currently receives special monthly compensation for loss of use of a creative organ. This decision in no way impacts that award. 5. Entitlement to a rating higher than 50 percent for obstructive sleep apnea Diagnostic Code 6847 contains the criteria for all sleep apnea syndromes whether obstructive, central, or mixed in nature. Under Diagnostic Code 6847, a 50 percent rating is warranted for sleep apnea requiring the use of a breathing assistance device such as a CPAP machine. A 100 percent rating is warranted for sleep apnea with chronic respiratory failure with carbon dioxide retention or cor pulmonale, or; sleep apnea requiring a tracheostomy. 38 C.F.R. § 4.97. The present claim for a higher rating was filed in August 2016. On VA examination in April 2017, the examiner diagnosed sleep apnea. It was noted that continuous medication was not required for control of the sleep disorder, and the Veteran did not require use of a breathing assistance device. However, the Veteran required the use of a CPAP machine. The examiner opined that the Veteran did not currently have any findings, signs, or symptoms attributable to sleep apnea. The examiner further opined that the sleep apnea did not impact the ability to work. In a November 2018 statement, the Veteran’s spouse stated that the Veteran used a CPAP machine nightly, but the Veteran still woke frequently. She stated that the Veteran still snored and gasped for air. The Veteran was limited to what positions he could sleep in because of the machine. The Veteran’s sleep apnea is rated 50 percent throughout the appeals period. The only higher schedular rating available for sleep apnea is a 100 percent rating which is warranted where there is chronic respiratory failure with carbon dioxide retention or cor pulmonale, or tracheostomy required. There is no evidence of any of those symptoms or circumstances in this case and no evidence of sleep apnea symptoms of similar severity. None of the evidence of record shows tracheostomy, or chronic respiratory failure with carbon dioxide retention or cor pulmonale. As a result, a 100 percent schedular rating for sleep apnea is not warranted. 38 C.F.R. § 4.97, Diagnostic Code 6847. The Board finds that the preponderance of the evidence is against the assignment of any higher rating and the claim must be denied. Service Connection Service connection may be established for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be established for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d) (2017); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Furthermore, service incurrence will be presumed for certain chronic diseases if manifest to a compensable degree within the year after active service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. A disability that is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a non-service-connected disability, which is aggravated by a service-connected disability. In such an instance, the Veteran is compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to service connection for a psychiatric disability, claimed as depression A November 1999 service examination report indicates that the Veteran was psychiatrically normal. On a November 1999 Report of Medical History, the Veteran indicated that he experienced excessive worry. The reporting examiner specified that the Veteran had excessive worry about weight gain. A June 2000 service retirement examination report found that the Veteran was psychiatrically normal. On a June 2000 Report of Medical History, the Veteran indicated that he did not experience depression or excessive worry. On VA examination in March 2017, the examiner diagnosed adjustment disorder with depressed mood. The examiner opined that the Veteran’s depressive symptoms were directly due to problems in dealing with the Social Security Administration (SSA) over disability benefits. The Veteran reported that he did not have any mental health problems or depression during service. The examiner noted that a service examination from November 1999 showed that the Veteran experienced excessive worry, which the Veteran stated was worry about weight gain. It was further noted that the June 2000 service separation examination showed that the Veteran denied having depression or any other mental health problems or symptoms. The Veteran reported that he began having symptoms of depression in 2014 after SSA initially denied his claim for disability. The Veteran further reported that although he was eventually awarded full disability from the SSA, he still experienced depression which he stated was triggered by continued disputations about the amount of disability payments. After conducting an examination and reviewing the record, the examiner opined that the Veteran’s psychiatric disorder was less likely than not incurred in or caused by service. The examiner explained that the Veteran denied that he had any depression during service, and the service medical records did not show endorsement of or treatment for depression during service. The examiner emphasized the Veteran’s report that his depression began after he was initially denied SSA disability benefits following his first stroke in 2013. In a March 2017 addendum, the VA examiner stated that although the Veteran expressed some distress due to problems resulting from the two strokes, during the examination the Veteran stated that depression was specifically due to and resulted from stress in dealing with SSA regarding disability coverage. The examiner stated that although the argument could be made that the strokes were the reason the Veteran had to deal with the SSA, the examiner was unable to comment further or make any further determination regarding the relationship between adjustment disorder and service-connected strokes without resorting to mere speculation. In a November 2018 statement, the Veteran’s spouse said that she noticed some depression a few months after the Veteran’s first stroke. She said that after his second stroke, he was so depressed he didn’t want to do anything. On private examination in January 2019, H.H.-G., Ph.D., H.S.P.P., diagnosed adjustment disorder with mixed anxiety and depressed mood. The Veteran told the examiner that his mental health issues began while he was in service. He stated that he had several moments when he was worrying about things he could not control, especially as his health was getting worse. The examiner cited to a November 1999 Report of Medical History in which the Veteran reported experiencing depression and excess worry. Statements from the Veteran’s family and friends were reviewed which endorsed that the Veteran’s psychiatric symptoms had been exacerbated since separation from service. The examiner reviewed psychiatric literature which detailed the emergence of mental health symptoms within active duty servicemen. The examiner also commented on the body of literature which detailed the connection between medical issues and psychiatric disorders. The examiner stated that due to the complex overlap of endorsed symptoms it was inconceivable to differentiate specific causation for disability. The examiner stated that all conditions may indeed contribute to the overall disability of the Veteran. The examiner opined that the Veteran had adjustment disorder that more likely than not began in service. The examiner stated that the adjustment disorder was aggravated by hypertension with nephrosclerosis, obstructive sleep apnea, ischemic stroke, erectile dysfunction, and residuals of septoplasty. The Board finds that service connection for a psychiatric disability is warranted on a secondary basis. Although the March 2017 VA examination report contains a negative nexus opinion regarding whether the psychiatric disability is directly related to service, the examiner could not offer an opinion regarding whether the Veteran’s psychiatric disability was related to other service-connected disabilities without resorting to speculation. Thus, the March 2017 VA examination report neither supports nor weighs against the claim on a secondary basis. The January 2019 private examination report is detailed and provides an opinion that the psychiatric disability is aggravated by the service-connected disabilities. The private examiner reviewed and commented extensively on what the service and post-service treatment records showed. The examiner supported the opinion with specific medical principles. Therefore, the January 2019 private examiner provided a competent and credible medical nexus between the Veteran’s currently diagnosed adjustment disorder and the Veteran’s service-connected disabilities. As the Veteran has a current diagnosis of a psychiatric disability, and as the most probative medical opinion of record links the psychiatric disability to the service-connected disabilities, the Board will resolve reasonable doubt in favor of the Veteran and find that a current psychiatric disability is related to the service-connected disabilities. Therefore, service connection for a psychiatric disability is warranted on a secondary basis. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Effective Date In order for benefits to be paid to any individual under the laws administered by VA, a specific claim in the form prescribed by VA must be filed. 38 C.F.R. § 3.151(a). A claim or application is defined by VA regulation as a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). An informal claim is any communication or action, indicating intent to apply for one or more benefits. 38 C.F.R. § 3.155(a). Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. 38 C.F.R. § 3.155(a). The general rule regarding the assignment of effective date for an award based on an original claim for VA benefits is that the effective date shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. An exception to the general rule applies if an application for benefits is received within one year from the date of a Veteran’s separation from active service, and an award is made on the basis of that application. In that limited situation, the effective date of the award is made retroactive to the day following the date of separation from service. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2). Otherwise, the effective date will be the later of the date of receipt of claim or the date entitlement arose. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2). VA has a duty to maximize a claimant’s benefits. Buie v. Shinseki, 24 Vet. App. 242 (2011); AB v. Brown, 6 Vet. App. 35 (1993); Bradley v. Peake, 22 Vet. App. 280 (2008). Therefore, a case encompasses all potential claims raised by the evidence, applying all relevant laws and regulations, regardless of whether the claim is specifically labeled. Szemraj v. Principi, 357 F.3d 1370 (Fed. Cir. 2004); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). A claim for benefits remains pending until it is finally adjudicated. 38 C.F.R. § 3.160(c); Adams v. Shinseki, 568 F.3d 956 (Fed. Cir. 2009). If a claim is left pending without a final adjudication, the claim may be addressed when a subsequent claim is adjudicated by the VA, in which case the effective date for any resulting award of benefits will be the effective date applicable to the earlier claim. Adams v. Shinseki, 568 F.3d 956 (Fed. Cir. 2009); Myers v. Principi, 16 Vet. App. 228 (2002). 7. Entitlement to an effective date earlier than December 4, 2013 for service connection for hypertension with nephrosclerosis, ischemic stroke, and erectile dysfunction On December 4, 2013, the Veteran initiated an informal claim for service connection for ischemic stroke during a phone call with AOJ personnel. An unsigned formal claim form was received by the AOJ on January 21, 2014. The Veteran signed in the witness space. In an October 8, 2014 phone conversation, the Veteran stated an intent to apply for compensation benefits. A formal claim for service connection for ischemic stroke was received on October 15, 2014. Service connection for hypertension status post ischemic stroke with nephrosclerosis and service connection for erectile dysfunction were granted by means of a December 2014 AOJ decision. A 60 percent rating was established for hypertension status post ischemic stroke with nephrosclerosis effective December 4, 2013. A 0 percent rating was established for erectile dysfunction effective December 4, 2013. Special Monthly Compensation (SMC) based on loss of use of a creative organ was also established effective December 4, 2013. An April 2017 rating decision found a clear and unmistakable error in the December 2014 rating decision which combined service connection for hypertension with service connection for the ischemic stroke. A separate 10 percent rating was established for ischemic stroke, effective December 4, 2013. On review of all evidence, both lay and medical, the Board finds than an earlier effective date is not warranted. The assignment of the December 4, 2013 effective date is based on the date of the informal claim for service connection for ischemic stroke during a phone call with VA personnel. Service connection for hypertension with nephrosclerosis, ischemic stroke, and erectile dysfunction were granted as a result of that informal claim. There is no dispute as to the date of receipt of that informal claim. The Board finds that there is no evidence of record prior to December 4, 2013, that can be interpreted as a claim, formal or informal, for service connection for hypertension with nephrosclerosis, ischemic stroke, or erectile dysfunction. That date of receipt of the claim was more than one year following separation from service. Therefore, the appropriate effective date is the date of receipt of the informal claim on December 4, 2013. The Board can find no basis for the assignment of any earlier effective date. Accordingly, the Board finds that the preponderance of the evidence is against the claim for an earlier effective date for service connection for hypertension with nephrosclerosis, ischemic stroke, and erectile dysfunction. Therefore, the appeal must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 8. Entitlement to an effective date earlier than August 18, 2016, for service connection for residuals of septoplasty, claimed as deviated septum On a VA Form 21-0966, date stamped as received by VA on August 18, 2016, the Veteran filed an intent to file a claim for compensation. On a VA Form 21-526EZ, stamped as received by VA on February 10, 2017, the Veteran filed a formal claim for service connection for a deviated septum. Service connection for residuals of septoplasty was established in an April 2017 rating decision, and a 0 percent disability rating was assigned, effective August 18, 2016. On review of all evidence, both lay and medical, the Board finds than an earlier effective date is not warranted. The assignment of the August 18, 2016 effective date is based on the date of receipt of the informal claim of entitlement to service connection for compensation, which he later supplemented with a formal claim for service connection for a deviated septum. Again, there is no dispute as to the date of receipt of that informal claim for compensation. The Board finds that there is no evidence of record prior to August 18, 2016, that can be interpreted as a claim, formal or informal, for service connection for residuals of a septoplasty, claimed as a deviated septum. That date of receipt of the claim was more than one year following separation from service. Therefore, the appropriate effective date is the date of receipt of the informal claim on August 18, 2016. The Board can find no basis for the assignment of any earlier effective date. Accordingly, the Board finds that the preponderance of the evidence is against the claim for an earlier effective date for service connection for residuals of a septoplasty, claimed as deviated septum. Therefore, the appeal must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 9. Entitlement to an effective date earlier than August 18, 2016, for service connection for obstructive sleep apnea In an October 8, 2014, phone conversation with VA personnel, the Veteran stated an intent to apply for compensation benefits. A formal claim for service connection for sleep apnea was received on October 15, 2014. Service connection for sleep apnea was denied in a December 2014 rating decision. Within a year of that decision, the Veteran submitted a statement from his spouse and private medical records. The previous denial of service connection for sleep apnea was confirmed and continued in a May 2015 rating decision. The Veteran was notified of the May 2015 decision and of his appellate rights but did not initiate an appeal of that issue. There is no indication that new and material evidence was received within the one year following the May 2015 decision that was pertinent to the claim for service connection for sleep apnea. 38 C.F.R. § 3.156(b). Thus, that decision became final. 38 U.S.C. §§ 7104, 7105. Therefore, in the absence of clear and unmistakable error, an effective date of the date of the October 2014 claim is not warranted. Rudd v. Nicholson, 20 Vet. App. 296 (2006). Notably, no allegation of a clear and unmistakable error has been raised with respect to the May 2015 rating decision. On a VA Form 21-0966, date stamped as received by VA on August 18, 2016, the Veteran filed an intent to file a claim for compensation. On a VA Form 21-526EZ, date stamped as received by VA on February 10, 2017, the Veteran filed a formal claim for service connection for sleep apnea. Service connection for obstructive sleep apnea was established by a May 2017 rating decision, which assigned a 50 percent rating, effective August 18, 2016. The Board is sympathetic to the Veteran’s situation. However, the legal authority governing effective dates is clear and specific, and the Board is bound by that authority. There is no claim for service connection for sleep apnea after the May 2015 final rating decision and before August 18, 2016. Thus, the Board finds that August 18, 2016, the date of receipt of the informal claim to reopen following a previous final denial of service connection for sleep apnea, is the appropriate effective date for service connection as that is the date of the application to reopen following a final disallowance of the prior claim for service connection. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. As there is no legal basis for assignment of any earlier effective date, and because the preponderance of the evidence is against the claim for any earlier effective date, and because clear and unmistakable error has not been alleged in the May 2015 rating decision, the Board finds that the claim for an earlier effective date must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Special Monthly Compensation Under 38 U.S.C. § 1114 (s), SMC is payable at the housebound rate if the Veteran has a single service-connected disability rated as 100 percent and either of the following are met: (1) there is additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or (2) he or she is permanently housebound by reason of service-connected disability or disabilities. The requirement of permanently housebound will be considered to have been met when the veteran is substantially confined to his house (ward or clinical areas, if institutionalized) or immediate premises due to a service-connected disability or disabilities which it is reasonably certain will remain throughout his lifetime. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). 10. Entitlement to special monthly compensation based on housebound criteria As of the promulgation of this decision, service-connected ischemic stroke is rated 100 percent from December 4, 2013, to June 1, 2014, and from May 11, 2016, through December 1, 2016. Throughout the entirety of the appeal period, the Veteran’s other service-connected disabilities consist of hypertension with nephrosclerosis, rated at 60 percent; erectile dysfunction, rated at 0 percent; and residuals of septoplasty, rated at 0 percent. Additionally, from August 18, 2016, service connection is in effect for obstructive sleep apnea, rated at 50 percent. As the Veteran’s service-connected ischemic stroke is rated at 100 from December 4, 2013, to June 1, 2014, and from May 11, 2016, through December 1, 2016, and the additional service-connected disabilities are independently rated 60 percent or more during those periods, the criteria for SMC based on housebound status for the periods from December 4, 2013, to June 1, 2014, and from May 11, 2016, through December 1, 2016, have been met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). As the Veteran does not have a service-connected disability rated at 100 percent at any other time during the appeal period, entitlement to SMC based on housebound status must be denied based on a lack of entitlement under the law for the periods other than from December 4, 2013, to June 1, 2014, and from May 11, 2016, through December 1, 2016. Sabonis v. Brown, 6 Vet. App. 426 (1994). REASONS FOR REMAND 1. Entitlement to service connection for a disability manifested by loss of equilibrium is remanded. On VA examination in April 2017, the examiner stated that the Veteran had never been diagnosed with an ear or peripheral vestibular condition. The Veteran reported that he developed significant loss of equilibrium after a second stroke in 2016. The Veteran stated that he had an off-balance feeling when standing up, with left-sided numbness and pain. The examiner stated that the Veteran did not have a current diagnosis of an inner ear abnormality or a peripheral vestibular disorder. The examiner opined that the loss of equilibrium was not secondary to a septoplasty because there was no biologically plausible explanation that would connect a septoplasty with loss of equilibrium. The examiner further opined that the loss of equilibrium was not likely secondary to hypertension, as the systolic blood pressure was mildly to moderately elevated and not to the level that would cause loss of equilibrium or lightheadedness. The Board appreciates the opinions of the April 2017 VA examiner. However, the examiner offered no opinion regarding any possible relationship between the Veteran’s loss of equilibrium and service-connected ischemic strokes. That is an especially significant omission as the Veteran reported developing significant loss of equilibrium after a second stroke in 2016, and in a November 2018 statement, the Veteran’s spouse stated that the Veteran had poor balance since the first stroke. When VA obtains an examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Remand is required to obtain an opinion regarding whether any connection exists between loss of equilibrium and service-connected ischemic strokes. 2. Entitlement to special monthly compensation based on the need for the aid and attendance of another person is remanded. SMC based on the need for aid and attendance of another is payable when the Veteran, due to service-connected disability, is permanently bedridden or has such significant service-connected disabilities as to be in need of regular aid and attendance. 38 U.S.C. § 1114(l). The criteria for determining when a Veteran is so helpless as to be in need of regular aid and attendance, including a determination that he is permanently bedridden, are contained in 38 C.F.R. § 3.352(a). 38 C.F.R. § 3.350(b)(3)-(4). The following will be considered in determining the need for regular aid and attendance: inability of claimant to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his daily environment. Bedridden, will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that the claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. 38 C.F.R. § 3.352(a). It is not required that all of the disabling conditions enumerated in 38 C.F.R. § 3.352(a) be found to exist before a favorable rating may be made. The particular personal functions which the Veteran is unable to perform should be considered in connection with his condition as a whole. It is only necessary that the evidence establish that the Veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the Veteran is so helpless, as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant’s condition is such as would require him to be in bed. They must be based on the actual requirement of personal assistance from others. 38 C.F.R. § 3.352(a). The requirements of 38 U.S.C. § 1114(s)(2) are met when a Veteran is substantially confined as a direct result of service-connected disabilities to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical area, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. 38 C.F.R. § 3.350(i)(2). The Board notes that the Veteran is service connected for hypertension with nephrosclerosis, rated at 60 percent; obstructive sleep apnea, rated at 50 percent; ischemic strokes, rated at 10 percent; erectile dysfunction, rated at 0 percent; and residuals of septoplasty, rated at 0 percent. The Board finds that further examination is needed to determine whether or not the Veteran needs that aid and attendance of another person due to the service-connected disabilities. The matters are REMANDED for the following action: 1. After obtaining appropriate authorization, obtain any VA and private treatment records identified by the Veteran that are not already of record. 2. Then, schedule the Veteran for a VA examination to determine the etiology of any disability manifested by loss of equilibrium. The examiner must review the record and must note that review in the report. All appropriate tests or studies should be accomplished, and all clinical findings should be reported in detail. The examiner should opine whether it is at least as likely as not (50 percent or greater probability) that loss of equilibrium had its onset in or is otherwise related to service. The examiner should also opine as to whether it is at least as likely as not (50 percent probability or greater) that loss of equilibrium was caused by the service-connected disabilities, so specifically include ischemic strokes. The examiner should further opine as to whether it is at least as likely as not (50 percent probability or greater) that loss of equilibrium has been aggravated (increased in severity beyond the natural progress of the disorder) by the service-connected disabilities, to specifically include ischemic strokes. If it is determined that there is another likely etiology for the loss of equilibrium, that should be stated. A complete rationale for all opinions expressed should be clearly provided. The examiner must consider the Veteran’s statements and all lay statements regarding onset in-service and statements regarding the continuity of symptomatology. 3. Schedule the Veteran for a VA aid and attendance examination. The examiner must review the claims file and should note that review in the report. The examiner should state whether or not the Veteran is confined to his home or premises due to the service-connected disabilities. The examiner should state whether or not the Veteran is bedridden. The examiner should state whether or not the Veteran has the inability to dress or undress himself, or to keep himself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. The examiner should state whether there are any other factors due to the service-connected disabilities which would require the aid and attendance of another person. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Layton, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.